This article presents arguments in support of the ANA's first position on education for nurses written in 1965 and discusses the effect of this statement on nursing education and practice over the past four decades. The similarity of the issues discussed at policy tables in 1965 and 2002 are addressed. The article ends with a challenge for nurses to advocate for better educated nurses with stakeholders, their patients and clients, in public and private sectors.
Key Words: American Nurses Association First Position on Nursing Education; entry into practice; nursing education; nursing shortage; nursing advocacy
This article has been updated and contact-hour credits are available.
The mission of this article is to turn the clock back and compare the nursing education scene of the 1960's to contemporary educational practice. Specifically, the authors will discuss the rationale underlying the American Nurses Association's 1965 statement on the education of nurses and trace its impact on the autonomy and the financial control of nursing education and practice. It will also compare the nurse force of the mid sixties to nurses in contemporary practice. The sentinel event to be examined is the impact of the American Nurses Association's First Position on Education for Nursing, published in December 1965 (ANA, 1965). This document, which divided the health and nursing community, took a stand on the level of education which the nurse should attain before she/he entered practice: "Education for those who work in nursing should take place in institutions of learning within the general system of education" (Committee on Nursing Education, 1965, p. 107).
The change in the delivery and financing of health care and the nursing shortage prompted the Online Journal in Nursing (OJIN) authors to re-examine the perennial question about the educational preparation of nurses and to challenge their colleagues to articulate their position on this timely subject. In times of shortage, there is always a call to reduce educational requirements and to change licensing and accreditation standards for professional nursing practice. The response to the millennial nursing shortage illustrates this pattern. In the spring of 2002, the American Association of Colleges of Nursing (AACN) is responding to a public relations campaign that claims that the AACN seeks to close associate degree (AD) programs, deny the RN license to AD graduates, and limit their entry into practice (P. Bednash, personal communications, 1 May 02; AACN, 2002a). The campaign appears to be directed toward forcing the Commission on Collegiate Nursing Education (CNE), the accreditation arm of the AACN, to change its mission and accredit associate degree programs in addition to baccalaureate and higher degree programs (P. Bednash, personal communication, 1 May 02).
ANA's First Position on Nursing Education
The writers of the first position paper on education for nurses,
The writers of the first position paper on education for nurses,the Committee on Nursing Education of the American Nurses Association, envisioned an orderly transition to an educational system with two levels - technical and professional.
the Committee on Nursing Education of the American Nurses Association, envisioned an orderly transition to an educational system with two levels - technical and professional. They recommended that in the future, all nursing education, technical and professional, would be based in colleges or universities. Persons interested in technical practice would enroll in junior or community colleges and earn associate degrees in two-year programs: "'¦minimum preparation for beginning technical nursing practice at the present time should be associate degree education in nursing" (Committee on Nursing Education, 1965, p. 108). Those interested in professional nursing would enroll in four-year programs in colleges or universities: "'¦minimum preparation for beginning professional nursing practice at the present time should be baccalaureate degree education in nursing" (Committee on Nursing Education, 1965, p. 107). Education for assistants in health service occupations would take place in short term, intensive pre-service programs in vocational-technical schools rather than through on the job training programs. Colleges and universities that offered programs in nursing were challenged to expand their programs. Hospitals were encouraged to work with junior and senior colleges in planning for nursing programs. The authors of the position statement also recommended that associate degree programs replace practical nursing programs. The cost of nursing education would be borne by all tax payors not just those who were hospitalized in institutions that operated schools of nursing. The rationale underlying the position paper considered the changing role of government, especially its investment in nursing education and manpower training, the changing pattern of education in the United States and the increasing availability of collegiate education for women, the expansion of science and technology and its impact on health and health care, and the new insights into the health problems of man (ANA, 1965). In an accompanying editorial, Barbara Schutt (1965) said that nurses were wasting their energies debating the merits of collegiate education for tomorrow's nurse. "For the facts of the matter are that the mood of the American public is to make collegiate education available for all our able youth, of which nursing students are only a part; and the nurse of the future is the one who will have to determine the role she will play at the time" (Schutt, 1965, p. 57).
The thirteen authors of the position statement did not refer to Congressional activity to pass some form of national health insurance or address how improving access to care for older or poor people would affect nursing education and nursing practice (ANA, 1965). This is interesting because the legislation that we know as Medicare and Medicaid was on the agenda of the Congress of the United States as the ANA's Committee on Education was drafting its document. The Committee's commentary on the role of government and its relevance to the issue of nursing education was limited to a discussion of federal initiatives to support the education of students, particularly the Nurse Training Act of 1964 (ANA, 1965).
The authors of the 1965 statement acknowledge that the thoughts and recommendations expressed in the position paper were not original. Historians of the period, notably Roberts (1954), describe the struggles to strengthen nursing education through the publication of curriculum guides and a national effort to accredit schools of nursing. Leaders emphasized the importance of liberal education as a preparation for nursing practice (Hanson, 1991). In one of the seminal reports on nursing education, Esther Lucille Brown (1948) observed that the extant system of nursing education was totally inadequate to meet the needs of society for nursing care. She made this claim after completing an assessment of nursing education between 1920 and 1940. Brown concluded that professional schools of nursing should be placed in degree-granting institutions. She also recommended that university schools be autonomous, that they seek clinical contracts with the best health care agencies, and that the schools emphasize student education rather than responsibility for patient care (1948). The public and professional response to the Brown report was business as usual.
However, the position paper published in the December, 1965, issue of the American Journal of Nursing (Committee on Nursing Education, 1965) did not fall on deaf ears.
As hospitals were positioning themselves to treat older patients who would require more nursing care... organized nursing recommended that hospitals close their schools of nursing and get out of the business of nursing education. The position paper was not received in the hospital or medical community as a friendly document.
Marketing explains some of the response that followed the release of the AJN article. Organized nursing and the academic nursing community were the audience for Brown's report, which had been commissioned by the Russell Sage Foundation. The American Journal of Nursing, the forum for the position paper, was accessible to the majority of registered nurses and their employers. Other social factors contributed to the reception of the American Nurses Association's position statement on education for nursing. In 1965, the era of the Great Society, Medicare and Medicaid legislation gave health insurance cards and access to care to older people and to the poor, whose health needs had not been adequately met. As hospitals were positioning themselves to treat older patients who would require more nursing care, a fact recognized by early Medicare reimbursement formulas, the American Nurses Association made its statement about hospital-based nursing education. Simply speaking, organized nursing recommended that hospitals close their schools of nursing and get out of the business of nursing education. The position paper was not received in the hospital or medical community as a friendly document.
By 1965, hospitals had been in the business of nursing education for almost one hundred years. Hospital schools produced a steady stream of students and new graduates. The lives of diploma nursing students were aptly described by Nutting (1926) "'¦heavy demands of the wards made it impossible for all students to attend their weekly lectures and it was always arranged that some students would choose to take very full notes and read them later to the assembled groups of less fortunate," (pp 339-340). In the mid sixties, most diploma students spent between 24 to 30 hours a week in hospitals. Students' spheres of learning encompassed the various services provided by the hospital. Student life included clinical experiences on the evening and night tours of duty and assignments on weekends. Physicians, associated with the hospital, taught nursing students in classrooms and on the wards. Students learned to meet the needs of patients, to work with the hospital's nursing and ancillary staff, and to accommodate to the hospitals' routines.
The authors of the position paper noted that the existing educational programs prepared workers for current practice and current structures. They reported, "'¦that more than three-fourths of the curriculums in the majority of schools continue to focus on the nursing of patients who are acutely ill and hospitalized," (Committee on Nursing Education, 1965, p. 111). It is not surprising that new diploma graduates required little orientation to the hospital workplace. The transition from senior student to new graduate was seamless. Many diploma graduates practiced in the settings where they completed training. Hospitals developed an individualized nursing ethos that was transmitted to students and new graduates. People spoke of a Mercy nurse or a Shadyside nurse.
The passage of Medicare and Medicaid in 1965 reminded hospitals of the founding purpose of their schools: to assure care of patients and an adequate nurse supply. In 1962, when the American Nurses Association published its Inventory of Professional Registered Nurses, 63% of the 532,118 registered nurses worked in hospitals (Marshall & Moses, 1965). It is difficult to abstract data about the educational preparation of nurses of this period because the ANA published the data collected by the State Boards of Nursing in their 1962 Inventory of Professional Registered Nurses. In the 1962 Inventory, the data familiar to the writers of the position paper, only 15 of the reporting states asked nurses about their educational preparation (Marshall & Moses, 1965). These authors estimated that between 75 and 85 percent of the 136,000 nurses in these states were graduates of hospital schools (Marshall & Moses, 1965). No data on baccalaureate or associate degree graduates were provided. The 1966 edition of Facts about Nursing reports that as of 15 October 1963, there were 1,142 schools of nursing (290 college, 818 hospital, and 34 independent). These schools enrolled 93,271 diploma, 6,356 associate degree, and 25,171 baccalaureate students (ANA, 1966). The National League of Nursing (1964), in its listing of state approved professional schools, described the college settings as 206 universities and 84 junior colleges. At the time of the position paper, 72 percent of all students studied in hospital schools.
However, the American Nurses Association (1966) also described enrollment trends, notably a decline in diploma admissions and the closure of some diploma schools in its 1966 Facts about Nursing. When the 1977-78 inventory was published, 71 percent of the registered nurses held diplomas and the rest held baccalaureate or associate degrees (Schulte, 1981). Associate degree graduates were still the new kids on the educational and practice block. In 1966, BSN graduates composed only 16 percent of the total nurse force (Schulte, 1981). However, their entry into hospital practice was described as reality shock, a mutual experience of new graduates and hospitals (Kramer, 1974). Diploma graduates were the matrix of hospital staffs. Years later, a country western song would describe the plight of a farmer whose wife left him at harvest time. At the end of 1965, hospital and diploma school administrators, who contemplated the ANA statement on their schools, could resonate to the refrain, "You picked a bad time to leave me, Lucille."
Looking back, it seems that the controversy around the 1965 position paper can be examined under three rubrics: autonomy and financial control, the nature of nursing practice, and the nursing supply. Framed in this way, the dialogue in 1965 resonates with contemporary discussions.
Autonomy and Financial Control
In 1965 nursing, especially hospital nursing, was highly controlled by hospitals and physicians. The position paper, describing the credentials necessary to practice nursing, was nursing's statement of autonomy. In the twenty-first century, it remains a declaration of independence from control by hospitals and organized medicine. By wresting control of the education and socialization of nurses away from hospitals, the ANA sought to do for nursing what the Flexner (1925) report did for medicine. The writings and experience of the period suggested that hospital schools were not about the education of students, but rather about assuring the care of patients. The education of student nurses was a means to an end. Because hospitals supported the schools and the students, they exerted influence over the curriculum, its implementation and the selection of faculty. However, the most direct influence exercised by hospitals over nursing, happened on nursing hospital units where practice standards and protocols set the template for the study and practice of nursing. Here, students learned what Walker (1967) called the ritualistic practices of nursing. Many of these transmitted nursing behaviors were not based on evidence or science. They were sets of practices, developed over time by hospitals and their nursing staffs, to deliver care to patients who were acutely ill. These systems or sets of practices were unexamined but deeply imbedded in the ward culture. They were imprinted on the minds and hearts of student nurses, who then transmitted these practices when they became staff nurses.
Strong bonds of loyalty developed between the hospital and its students, graduates and nurses. While the relationship of loyalty could be labeled paternalistic or dependent, a mutual trust existed between the hospitals and their nursing staffs. Nurses could be counted upon to help out in times of shortage and to give the best interpretation to the actions of their employers. Nurses defended the actions of hospitals and physicians, and recommended their hospital to family and friends. Hospitals, for their part, knew and recognized the members of their nursing staffs. They developed organizational structures that gave nursing issues a voice that was heard separately from the opinions expressed by other clinical or patient care services. Hospitals relied on the commitment and stability of its staff.
However, even though hospitals of the sixties valued nurses, the culture of hospitals diluted the autonomy of nursing because it over-emphasized medical authority. Hospitals exerted an amazing influence on nursing identity because their schools were gateways into the profession, and as the major employers of nurses, hospitals controlled the supply and demand. This monopoly depressed nursing salaries and limited career opportunities. Hospitals also represented and spoke for nursing. They provided data about nursing education and nursing practice to private and public groups and generally shaped public opinion about nursing. Nursing practice was almost synonymous with hospital nursing practice. Although nurses were registered as professional nurses in their states of practice, hospital policies gave decisional authority, even over matters of nursing practice, to attending physicians. The "ask your doctor" mantra reinforced the commonly held view that nursing was an occupation, that nurses were employees, and that nurses were handmaidens of physicians. Physicians' orders, the ritualistic routines of hospital practice, and a focus on the care of acutely ill persons shaped the domain of nursing.
In writing the position paper, the American Nurses Association's Board of Directors differentiated the primary aim of nursing education from the primary aim of nursing service.
In adopting the statement on nursing education, the nursing community expressed its belief that nursing was prepared to set its own standards in an environment where hospital administrators and physicians did not control the playing field.
In addressing the primary role of education, they said that its aim was "to provide an environment in which the nursing student can develop self-discipline, intellectual curiosity, the ability to think clearly, and acquire the knowledge necessary for practice. Nursing education reaches its ultimate aim when recent advances in knowledge and findings from nursing research are incorporated into the program of study within nursing" (Committee on Nursing Education, 1965, p. 111). In adopting the statement on nursing education, the nursing community expressed its belief that nursing was prepared to set its own standards in an environment where hospital administrators and physicians did not control the playing field. Nurse leaders were also making a case for the role that better educated nurses could play in improving the care of patients. Long before the position paper was written, nurses had argued that universities were the settings where the nursing profession could develop a knowledge base and a research agenda. The position paper was a statement about the need for nursing science and nursing research.
In attempting to differentiate the practice of nursing from the practice of medicine and the demands of hospitals, nurse leaders were laying the framework for the contemporary practice of professional nursing.
This thrust was consistent with what the authors called '¦ "the ultimate aim of nursing education and nursing service, the improvement of nursing care" (Committee on Nursing Education, 1965, p. 111). In attempting to differentiate the practice of nursing from the practice of medicine and the demands of hospitals, nurse leaders were laying the framework for the contemporary practice of professional nursing.
The Nature of Nursing Practice
In the sixties, community hospitals followed the lead of academic health centers and invested in technology. Medical and nursing practice became more specialized and technologically sophisticated. This differentiation affected practice and staffing patterns. For example, when cardiovascular nursing and neuroscience nursing emerged, nurses were no longer interchangeable between medical surgical units. This evolution in therapy and care affected nursing education. At the time of the position statement, the seamless web between diploma schools of nursing and hospitals was beginning to unravel. Even hospital schools could not produce new graduates able to perform in intensive care units and labor and delivery suites. The complexity and unpredictability of high technology practice required that nursing professionals be grounded in science and critical thinking, not ritualistic practice.
The complexity and unpredictability of high technology practice required that nursing professionals be grounded in science and critical thinking, not ritualistic practice.
However in 1965, hospitals were more concerned about assuring a steady supply of nurses to care for an expanding and older patient population. They were willing to invest in staff development if this assured that the new staff could carry out clinical and hospital protocols. Their orientation to the practice of nursing was very practical and focused. When third party payers, especially Medicare, required additional documentation, hospitals assigned nurses more responsibility for clinical record keeping and preparing and processing charge slips. The demands of high technology care, the increased volume of paper work, and the responsibility of coordinating care provided by ancillary workers changed the scope of nursing practice.
The Nursing Supply
On the educational front there were changes too. Perhaps the most dramatic response to the position paper occurred in associate degree education. Data from the most recent national sample survey of registered nurses (Spratley, Johnson, Sochalski, Fritz & Spencer, 2000) show pre and post- licensure educational patterns of registered nurses. Twenty-three percent hold diplomas, 34.3 percent hold associate degrees and 32.7 percent have a baccalaureate education.(Approximately 10.2 percent of the registered nurses hold graduate degrees.) However, 55.4 percent of the RNs, who obtained their initial nursing education in the past 5 years, graduated from associate degree programs; 38 percent from baccalaureate degree programs and 6 percent from diploma schools (Spratley et. al, 2000).
Because hospitals have remained the main site of employment, nurse employment and staffing patterns have been directly affected by changes in reimbursement policies, especially Medicare reimbursement. In 1983, prospective payment legislation changed Medicare's reimbursement formula for acute care hospitals. Payment based on the diagnostic related groups encouraged a different form of utilization of inpatient care than payment under fee for service methodologies. Under these new financial incentives, patients were admitted later and discharged earlier from hospitals. Hospitals responded to lower census and decreased revenues by closing nursing units and reducing nursing and ancillary staff. Ironically, shortened hospital stays are characterized by an intensity of care that required more nurses. By the late eighties, the widespread difficulties in recruiting and retaining registered nurses triggered a federal commission to study the nursing shortage (Secretary's Commission on Nursing, 1988). The 25 member Commission reported that the shortage of RNs was real, of significant magnitude, present in all health care settings and in all nursing practice areas (Secretary's Commission on Nursing, 1988, p. v). The Commission also found that the problem in this nursing shortage was on the demand side. Lynaugh (1988), commenting on the report, noted that nursing shortages were often about demand, because during the twentieth century the real number of nurses had risen steadily in relationship to the population.
After prospective payment legislation, the acuity of illness of hospitalized patients and the level of high technology medicine required hospitals to provide more complex nursing care.
At a time when hospitals' demand for nurses was insatiable, hospitals also experienced the first real competition for professional nurses. Ambulatory clinics, day surgery centers, home care, and skilled nursing facilities, expanded because of the early discharge of sick people into the community, competed with hospitals for their experienced nurse force.
Nurses were also busier after 1983, because they "substituted," that is, assumed responsibility for additional patient care services because of reductions in ancillary staff. At a time when hospitals' demand for nurses was insatiable, hospitals also experienced the first real competition for professional nurses. Ambulatory clinics, day surgery centers, home care, and skilled nursing facilities, expanded because of the early discharge of sick people into the community, competed with hospitals for their experienced nurse force.
In the past, the typical response to an increased demand for nurses was to increase the nursing supply. However, the shortage of the late 1980s introduced a new variable into the supply/demand equation of nursing. Labeled "trouble in the pipeline," enrollment data showed a decline of students in all nursing programs (Green, 1987). Interviews with guidance counselors and teachers revealed that young men and women were not that interested in nursing. For the academically oriented man and woman, medicine, pharmacy, business, or computer science held more appeal. Nursing was judged to be too demanding, too undervalued, and too unrewarding. The female dominance of the profession continued to challenge young men and feminists.
How do the issues of autonomy and financial control of nursing education, the nature of nursing practice and nursing supply play out in this century some thirty-five years after the publication of the position paper? In the area of autonomy and control, there are similarities and differences between the state of nursing in 1965 and in 2002. Hospitals no longer dominate the health care delivery system, although they continue to employ the largest group of nurses. In 2000, fifty-nine percent of registered nurses worked in the nations' hospitals, while only 6 percent of new graduates completed hospital based educational programs (Spratley et al., 2000). The struggle to achieve autonomy in practice continues, but it is played out in varied work sites and in the legislature of each state. Professional and financial autonomy and career advancement are directly correlated with higher education. However, the level of education that has given nurses more autonomy and professional control is a masters' degree in a clinical specialty or primary care and certification in a field of advanced practice.
The nursing shortage of the
Failure to resolve work place issues contributes to nursing shortages, at least nursing shortages in hospitals.
millennium has refocused attention on nursing practice issues. Failure to resolve work place issues contributes to nursing shortages, at least nursing shortages in hospitals. Efforts to describe, quantify, and address these work force issues and their relationship to health care outcomes and cost is methodologically complex. The Institute of Medicine (IOM) in their study of nursing staff in hospitals and nursing homes listened to nurses about the lack of satisfaction in their work (Wunderlich, Sloan & Davis, 1996). Specifically, they heard testimony about the restructuring and re-engineering of clinical services in hospitals and the effect of these reorganizations on staffing patterns and quality of care. Unfortunately, the IOM committee was unable to document the relationships of organizational restructuring and staffing patterns on the quality of care in hospitals (Wunderlich et. al., 1996). A decade earlier, the National Commission on Nursing (1981) derived five themes from public hearings held in six regions of the country: status and image of nursing, interface between education and practice, effective management of nursing resources (salaries, schedules, benefits), relationships among nursing, medical staff and hospital administration, and the maturing of nursing as a self-determining profession (autonomy, scope of practice) (National Commission on Nursing, 1981).
Another insight into the important role of the quality of the work place on staffing is provided in the literature on magnet hospitals. The original work on this concept dates back to an American Academy of Nursing Study. McClure, Poulin, Sovie & Wandelt (1983) identified 41 hospitals that were successful in attracting and retaining nurses. They sought to determine the shared organizational characteristics of these institutions. In the original study (1983), magnet hospitals were defined as places where nurses had autonomy, control over practice settings, and working relationships with physicians. Attractive practice environments had the following characteristics: adequate support services, enough RN staff to provide high quality care, time to discuss patient problems with RN colleagues, control of practice, opportunity to participate in policy decisions, a powerful chief nurse executive and recognition of the work of registered nurses (McClure et. al., 1983). Kramer (1990) and Aiken, Havens & Sloane (2000) have revisited the magnet concept. Their studies seek to link nurses' perceptions about practice and organizational environments with outcomes and quality of care. Today, many nurses and the labor unions and professional associations that speak for them cite work place issues as a cause of the current shortage in nursing, at least in hospital practice (AACN, 2002b).
American hospitals have undergone three waves of organizational change in the past two decades (Norrish & Rundall, 2001). Each change has directly affected work role, workload and control of work (Norrish & Rundall, 2001). Contemporary literature about the third wave of change reveals that nurses in managed-care environments feel rushed, unable to complete the basic requirements of their care responsibilities, and powerless to bring about change (De Carlo, 2002). Their assignments are increased, they work with fewer support services, and they are pressured to move from unit to unit as patient census fluctuates (Norrish & Rundall, 2001). Nurses employed by hospitals feel a disproportionate responsibility for oversight and co-ordination of care provided by unlicensed personnel. There are also concerns about the increased use of local or national nursing agencies. Although hospitals pay agencies significantly more than they pay their regular staff, hospital staff nurses do not believe that nursing responsibilities are equitably shared between staff and agency nurses (Knox, Irving, & Gharrity, 2001).
Seventy-five percent of the nurses who completed the American Nurses Association's online survey felt that the quality of nursing care had declined in their work setting in the last two years because of inadequate staffing, decreased nurse satisfaction, and delay in providing basic care (ANA, 2001).
Hospital nurses say they are voiceless in contemporary managed care environments.
Seventy percent of these nurse respondents were employed by hospitals; 23 percent had been in nursing for more than 25 years (The mean age of respondents was 43.4 percent); 61.4 percent worked full time and 58.1 percent held a baccalaureate or higher degree. (ANA, 2001). Hospital nurses say they are voiceless in contemporary managed care environments. The flattened health care hierarchies do not respond to or even hear their concerns, especially concerns about mandatory overtime. Many nurses say that they do not know to whom they should complain or bring suggestions. For some, labor unions offer the only forum for their issues. Others ask for state or federal intervention (Sullivan, 2001).
Another significant difference in the contemporary practice environment is the loss of trust and loyalty that characterized the hospital and nursing community of the sixties. Nurses feel alienated. ANA's online survey of 7,299 nurses revealed that 54 percent of those surveyed would not recommend nursing to their children or friends (ANA, 2001). For their part, hospital systems view nurses as free agents that have little commitment to the institutional mission or goals.
There continues to be demographically induced concerns about the adequacy of the nursing workforce. In 1965, concern about newly enrolled Medicare beneficiaries focused attention on the nurse supply. Today, analysts worry about a serious nursing shortage when the baby boomer generation reaches 65 at the end of the decade (Buerhaus, Staiger & Auerbach, 2000). In the sixties, nursing was an attractive option for young women. Today, enrollment in all levels of nursing education has been depressed for six years. In the 1966 Facts about Nursing, the authors reported that 621,000 were registered. The typical profile of the new graduate, who joined this group in the sixties, was a mid-twenties woman who completed her program of studies in a hospital school of nursing. Today's new nurse is a mid-thirties graduate of an associate degree program. She or he joins a nurse force that had grown to 2,694,540 (Spratley et al., 2000). However, given the diminished number of students in nursing programs and the age of new graduates, it is not surprising that the average age of the practicing registered nurse is 45.2 (Spratley et al., 2000). In 1980, 26 percent of the RNs were under 30; by 2000, less than 10 percent were under 30 (Spratley et al., 2000). In the sixties, concerns about nursing were framed within the environment of the acute care hospital. Today, diminishment of the nurse force is a concern of the entire health care delivery system. Secretary Thompson has called the nursing shortage a critical national priority (Bush Administration, 2002).
The face of nursing has changed in the period following the publication of the position paper.
Registered nurses are undereducated members of the health care team, when compared with physicians, social workers, physical therapists, pharmacists, and dieticians to name a few.
The number of registered nurses has increased dramatically and today's workforce represents three levels of nursing education. In the not too distant future, associate degree nurses will provide the majority of patient care in hospitals and community centers. If you view the 1965 statement as a call to close hospital schools of nursing and move all nursing education inside the walls of colleges or universities, then the American Nurses Association was successful.
Under-educated members of the health team rarely sit at policy tables or are invited to participate as members of governing boards.
If, however, you view the position as a mandate for a more educated nurse force to better patient care, the goal has not been achieved. Registered nurses are undereducated members of the health care team, when compared with physicians, social workers, physical therapists, pharmacists, and dieticians to name a few. Looking beyond the clinical environment, the nurse work force also lacks the educational credentials of persons in the business, investor, and insurance communities that now play significant roles in health care decisions. Under-educated members of the health team rarely sit at policy tables or are invited to participate as members of governing boards. Consequently, there is little opportunity for the majority of practicing nurses to engage in clinical or health care policy.
Quality care is easy to describe but difficult to measure. Because technical and professional nurses write the same licensing examination, hospitals, as the major employers, do not differentiate among the educational levels of staff nurses in patient care responsibilities or salary. Given the educational mix of registered nurses in the care environments, the number of health professionals involved in hospital-based practice and the complexity of care, it is difficult to identify any factor, such as the educational level of the nurse, in studies of health care outcomes. Consequently, the measured impact of professional nursing on patient care is ambiguous and unproven. As more care is provided in community settings and more nurses work in this field (Spratley et al., 2000), the lack of a liberal arts education of a majority of nurses in community practice affects their application of knowledge about complex human and social systems. In the community, staff nurses are challenged to move beyond the technical and the technological dimensions of practice and promote healthy life styles, teach their patients and families self care and disease management, and link them with community resources. The writers of the position paper did not describe an ideal ratio of technical to professional nurses. However, the constellation of nurses, who will practice at the end of the decade, does not seem to represent to these OJIN authors the vision of the Committee on Nursing Education. It is time for nursing leaders to write and implement a second position on education for nurses that is grounded in the human, clinical, and professional realities of the twenty-first century.
Sister Rosemary Donley, RN, PhD, C-ANP, FAAN
Sister Rosemary Donley, R.N., Ph.D., F.A.A.N., is an Ordinary Professor of Nursing and Director of a federally funded Community/Public Health Nursing Graduate Program at The Catholic University of America, Washington, D.C. and a General Councilor and the Vice President for Advancement of the Sisters of Charity of Seton Hill. Sister Rosemary Donley received a diploma from the Pittsburgh Hospital School of Nursing and holds a B.S.N. from St. Louis University and a M.N.Ed. and Ph.D from the University of Pittsburgh. She is a certified adult nurse practitioner. Her clinical and research interests are health policy, clinical decision making and health care literacy.
Sister Rosemary is a Fellow in the American Academy of Nursing and a member of the Institute of Medicine. She served as Executive Vice President (1986-97) and Dean of Nursing (1979-86) at The Catholic University of America. She was also a Robert Wood Johnson Health Policy Fellow. She is past President of the National League for Nursing and Sigma Theta Tau International Honor Society of Nursing, and past Senior Editor of Image: The Journal of Nursing Scholarship. Sister Rosemary serves on civic, college and health system boards and the Board of the Catholic Health Care Association. She sits on the editorial boards of five journals. She has served as a member of the Secretary of Health and Human Service's Commission on Nursing; has been a consultant to the U.S. Army and Navy Medical Commands; and is the recipient of six honorary degrees. She also received the Nell J. Watts Lifetime Achievement in Nursing Award.
Sister Rosemary has over 95 publications and has presented papers throughout the United States, Kenya, Spain, The Peoples Republic of China, Puerto Rico, the Philippines, Guam, Okinawa, Japan, Korea, Taiwan, Hong Kong, Brazil, Argentina, Germany, Israel, Canada, Russia, Azerbaijan, Georgia and Armenia. She has also participated in numerous seminars, panel discussions, and workshops in the United States.
Sister Mary Jean Flaherty, RN, PhD, FAAN
Sister Mary Jean Flaherty, R.N., PhD, FAAN is an Ordinary Professor of Nursing at The Catholic University of America, Washington, D.C. Sr. Mary Jean Flaherty received a diploma from the Pittsburgh Hospital School of Nursing and holds a B.S.N. from Duquesne University and M.S.N. and a PhD in Curriculum and Supervision from the University of Pittsburgh. She is a maternal-child clinical nurse specialist. Her research interests are grandmothers, post-partum care, breast-feeding, and mentorship. Her work has been funded by the Department of Health and Human Services, The Catholic University of America, and Sigma Theta Tau International.
Sister Mary Jean is a Fellow in the American Academy of Nursing. She has recently served as Dean of Nursing, Chair of the Graduate Program, Nursing of the Developing Family, and Director of the Doctoral Program at the Catholic University of America. Sister Mary Jean Flaherty has also served as a WHO nurse consultant to Indonesia and as an educational consultant. She is currently a program evaluator for the National League for Nursing. She has also held various positions on the Board of Review, Baccalaureate and Higher Degree Programs, National League for Nursing.
Sister Mary Jean has served on college and health system boards including Seton Hill College; Bon Secours Health System, Inc.; Jeannette Hospital; The National Commission on Nursing Implementation Project ; and the Committee of Graduate Nursing Education, China Medical Board. She was appointed as an External Evaluator for State-Wide Nursing Review, Board of Regents Commonwealth of Massachusetts (1984) and as a Doctoral Site Visitor for the Texas Higher Education coordinating Board at the University of Texas at Arlington, Houston and Galveston (1995). Sister Mary Jean has also served as Middle States and Southern Regional Evaluator of colleges and universities.
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